PERSISTENT DECOMPENSATED HEART FAILURE POST-TAVR SHOULD PROMPT INVESTIGATION FOR INTRACARDIAC FISTULA DEVELOPMENT.

Case Presentation: A 75-year-old male underwent TAVR in February of 2023 with a Sapien 3 OD29mm valve for severe symptomatic aortic stenosis. He had no known history of intracardiac shunt and right ventricular function was normal at baseline. Soon after TAVR implantation, he required admission for acutely decompensated heart failure. The valve was functioning well, and right heart catheterization demonstrated a step up from the RA to RV. However, despite further evaluation with a bubble study and TEE, no shunt was demonstrated. He was then admitted 2 years later for heart failure. He had evidence of right-sided heart failure with pre-capillary pulmonary hypertension. High clinical suspicion for Aorto-right ventricular fistula (ARVF) prompted a repeat right heart catheterization, which demonstrated step-up in oxygenation from RA to RV. A TEE was performed by a structural imager that clearly demonstrated a left-to-right shunt due to ARVF in the gastric view. His case was discussed with the structural cardiology team but he was not a candidate for ARVF repair. He eventually improved with diuresis and was discharged.

Discussion: TAVR is generally recognized as a safe and less invasive alternative to surgical aortic valve interventions in severe aortic stenosis. Nonetheless, there are several known complications of TAVR including annular rupture, tamponade, infective endocarditis, stroke, conduction defects, and coronary obstruction. A lesser-known complication is the formation of intra cardiac fistulas which have been reported at an incidence of around 0.5%. The most common intracardiac fistula described post-TAVR was interventricular, followed by aorto-right ventricular fistula (ARVF). ARVF is a rare but recognized complication of TAVR. Post-TAVR, heart failure exacerbations are common. In the absence of more common complications such as heart block, arrhythmias, and valve dysfunction, advanced cardiac imaging and hemodynamic assessment should be considered. New RV dilation, dysfunction or an unexplained oxygenation step-up during invasive assessment are clues that can prompt further work-up.

Conclusions: Our case highlights the significant hemodynamic consequences that can occur when diagnosis is delayed. In some cases, repair with either percutaneous closure devices or surgical closure may be indicated. Our case highlights an example where persistent clinical suspicion, despite a preliminarily negative workup, uncovered an ARVF in a post-TAVR patient